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CERTIFICATION OF COMPLIANCE AGREEMENT

BETWEEN THE
OFFICE OF INSPECTOR GENERA OF THE
DEPARTMENT OF HEALTH AND HUM SERVICES
AN
THE HARS COUNTY HOSPITAL DISTRICT

I. PREAMLE
The Hars County Hospital District (HCHD) hereby enters into ths Certification
of Compliance Agreement (CCA) with the Office of Inspector General (OIG) of the
United States Departent of Health and Human Services (HHS). Contemporaneously
with this CCA, HCHD is entering into a Settlement Agreement with the United States.

The effective date of this CCA shall be the date on which the final signatory of this
CCA executes this CCA (Effective Date). Each one-year period, beginng with the one-
year period following the Effective Date, shall be referred to as a "Reporting Period."

II. INTEGRITY REQUIMENTS

HCHD shall, for a period of thee years from the Effective Date of this CCA:

A. Continued Implementation of Compliance Program. HCHD shall continue to


implement its Compliance Program, as described in the attched Declaration (which is
incorporated by reference as Appendix A), and continue to provide and make available to
the Compliance Program, at a minimum, the same aggregate level of resources curently
provided, throughout ths time period. HCHD may amend its Compliance Program and
support functions as it deems necessary, so long as those amendments are consistent with
the overall objective of ensuring compliance with the requirements of Medicare,
Medicaid, and all other Federal health care programs, as defined in 42 U.S.C. § 1320a-
7b( f).

B. Reporting of Overpayments. HCHD shall promptly refund to the appropriate


Federal health care program payor any identified Overpayment(s). For purposes of ths
CCA, an "Overpayment" shall mean the amount of money HCHD has received in excess
ofthe amount due and payable under any Federal health care program requirements. If, at
any time, HCHD identifies or learns of any Overpayment, HCHD shall notify the payor
the
(~, Medicare fiscal intermediary or carrier) within 30 days after identification of

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Overpayment and take remedial steps withn 60 days after identification (or such
additional time as may be agreed to by the payor) to correct the problem, including
preventing the underlying problem and the Overpayment from recurring. Also, with 30
days after identification of the Overpayment, HCHD shall repay the Overpayment to the
appropriate payor to the extent such Overpayment has been quantified. If not yet
quantified, within 30 days after identification, HCHD shall notify the payor of its efforts
to quantify the Overpayment amount along with a schedule of when such work is
expected to be completed. Notification and repayment to the payor shall be done in
accordance with the payor's policies and, for Medicare contractors, shall include the
information contained on the Overpayment Refud Form, provided as Appendix B to ths
CCA. Notwithstanding the above, notification and repayment of any Overpayment
amount that is routinely reconciled or adjusted pursuant to policies and procedures
established by the payor should be handled in accordace with such policies and
procedures.

C. Reportable Events. HCHD shall report to OIG in writing withi 30 days after
makng a determnation (after a reasonable opportnity to conduct an appropriate review
or investigation of the allegations) that there is a Reportable Event, which shall mean
anything that involves: (1) a substantial Overpayment, (2) a matter that a reasonable
person would consider a probable violation of criminal, civil, or administrative laws
applicable to any Federal health care program for which penalties or exclusion may be
authorized; or (3) the fiing of a bankptcy petition by HCHD. In such report, HCHD
shall include the following information:

1. If the Reportable Event results in an Overpayment, the report to OIG


shall be made at the same time as the notification to the payor required in
Section II.B, and shall include all ofthe information on the Overpayment
Refund Form, as well as:

a. the payor's name, address, and contact person to whom the


Overpayment was sent; and

b. the date of the check and identification number (or electronic


transaction number) by which the Overpayment was repaid/refunded;

2. a complete description of the Reportable Event, including the relevant


facts, persons involved, and legal and Federal health care program
authorities implicated;
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3. a description ofHCHD's actions taken to correct the Reportable Event;
and

4. any further steps HCHD plans to take to address the Reportable Event
and prevent it from recurrng.

5. If the Reportable Events involves the filing of a bankptcy petition, the


report to the OIG shall include documentation of the filing and a description
of any Federal health care program authorities implicated.

D. Notification of Governent Investigation or Legal Proceedings. With 30


days after discovery, HCHD shall notify OIG, in writing, of any ongoing investigation or
legal proceeding known to HCHD conducted or brought by a governental entity or its
agents involving an allegation that HCHD has commtted a crime or has engaged in
fraudulent activities. This notification shall include a description of the allegation, the
identity of the investigating or prosecuting agency, and the status of such investigation or
legal proceeding. HCHD shall also provide written notice to OIG within 30 days after the
resolution of the findings and/or
the matter, and shall provide OIG with a description of

results of the investigation or proceedings, if any.

E. Anual Reporting Requirements. HCHD shall submit to OIG annually a report


that sets forth the following information for each Reporting Period (Anual Report):

1. A description of any material amendments to its Compliance Program


and the reasons for such changes;

2. Any changes to the level of resources dedicated to its Compliance


Program and the reasons for such changes;

3. A summary of all internal or external reviews, audits, or analyses of its


Compliance Program (including, at a minimum, the objective of the review,
audit, or analysis; the protocol or methodology for the review, audit, or
analysis; and the results of the review, audit, or analysis) and any corrective
action plans developed in response to such reviews, audits, or analyses;

4. A summary of all internal or external reviews, audits, or analyses related


to Medicare secondary payer claims (including, at a minimum, the objective
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of the review, audit, or analysis; the protocol or methodology for the
review, audit, or analysis; and the results of the review, audit, or analysis)
and any corrective action plans developed in response to such reviews,
audits, or analyses;

5. A report of the aggregate Overpayments that have been retued to the


Federal health care programs. Overpayment amounts shall be broken down
into the following categories: inpatient Medicare, outpatient Medicare,
Medicaid (report each state separately, if applicable), and other Federal
health care programs. Overpayment amounts that are routinely reconciled
or adjusted pursuant to policies and procedures established by the payor do
not need to be included in this aggregate Overpayment report; and

6. A certification by the Compliance Officer that: (a) to the best of his or


her knowledge, except as otherwise described in the Anual Report, HCHD
is in compliance with the requirements of this Section II; and (b) he or she
has reviewed the Anual Report and has made reasonable inquiry regarding
its content and believes that the information in the Anual Report is
accurate and trthfuL.

The first Anual Report shall be received by OIG no later than 60 days after the end of
the first Reporting Period. Subsequent Anual Reports shall be received by OIG no later
than the annversar date of the due date of the first Annual Report.

F. Notifications and Submission of Annual Reports. Unless otherwise specified in


writing after the Effective Date, all notifications and Anual Reports required under this
CCA shall be submitted to the following addresses:

oro: Admnistrative and Civil Remedies Branch


Office of Counsel to the Inspector General
Office of Inspector General
U.S. Departent of Health and Human Services
Cohen Building, Room 5527
330 Independence Avenue, S.W.
Washington, DC 20201
Telephone: 202-619-2078
Facsimile: 202-205-0604

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HCHD: Walter E. Freitag, Jr.
Vice President Corporate Compliance
Harrs County Hospital District
2525 Holly Hall Street
Houston, Texas 77054
Telephone: 713-566-6461
Facsimle: 713-566-6543

With a copy to:

Mercedes Leal
Haris County Attorney's Office
Harris County Hospital District
2525 Holly Hall, Suite 190
Houston, Texas 77054
Telephone: 713-566-6550
Facsimile: 713-566-6558

Unless otherwise specified, all notifications and report required by ths CCA may be
made by certified mail, overnght mail, hand delivery, or other means, provided that there
is proof that such report or notification was received. For puroses of ths requirement,
internal facsimile confirmation sheets do not constitute proof of receipt.

G. OIG Inspection, Audit, and Review Rights. In addition to any other rights OIG
may have by statute, regulation, or contract, OIG or its duly authorized representative(s)
may examine or request copies ofHCHD's books, records, and other documents and
supporting materials and/or conduct on-site reviews of any ofHCHD's locations for the
purose of
verifyng and evaluating: (a) HCHD's compliance with the terms of ths
CCA; and (b) HCHD's compliance with the requirements of the Federal health care
programs in which it participates. The documentation described above shall be made
available by HCHD to OIG or its duly authorized representative(s) at all reasonable times
for inspection, audit, or reproduction. Furthermore, for purposes of this provision, OIG
or its duly authorized representative(s) may interview any ofHCHD's employees,
contractors, subcontractors, or agents who consent to be interviewed at the individual's
place of business during normal business hours or at such other place and time as may be
mutually agreed upon between the individual and OIG. HCHD shall assist OIG or its
duly authorized representative(s) in contacting and arranging interviews with such
individuals upon OIG's request. HCHD's employees may elect to be interviewed with or
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without a representative of HCHD present.

H. Document and Record Retention. HCHD shall maintain for inspection all
documents and records relating to reimbursement from the Federal health care programs,
or to compliance with this CCA, for four years (or longer if otherwise required by law)
from the Effective Date.

III. BREACH AND DEFAULT PROVISIONS

HCHD is expected to fully and timely comply with all of the Integrity
Requirements set forth in this CCA.

A. Stipulated Penalties for Failure to Comply with Certain Obligations. As a


contractual remedy, HCHD and OIG hereby agree that failure to comply with the Integrty
Requirements set forth in this CCA may lead to the imposition of the following monetary
penalties (hereinafter referred to as "Stipulated Penalties") in accordance with the
following provisions.

1. A Stipulated Penalty of $2,500 (which shall begin to accrue on the day


after the date the obligation became due) for each day HCHD fails to establish and
implement any of the following compliance program elements as described in Section II
and the Declaration attched to ths CCA as Appendix A:

a. a Compliance Officer;

b. a Compliance Committee;

c. a written Code of Conduct for Federal Health Care Programs

d. written Policies and Procedures;

e. the annual training of the Board of Managers, officers, directors,


employees, and other persons who provide patient care items or
services on behalf of HCHD, or who perform biling or coding
functions on behalf of H CHD, and the availability of annual training
for medical staff;

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f. biling and codig compliance and other personnel who perform
periodic reviews to monitor HCHD's compliance with Federal health
care program requirements, including, but not limited to biling and
coding reviews;

g. a Disclosure Program;

h. Ineligible Persons screening and removal requirements; and

i. notification of governent investigations and legal proceedings.

2. A Stipulated Penalty of $2,500 (which shall begin to accrue on the day


after the date the obligation became due) for each day HCHD fails to submit the Anual
Reports to OIG in accordance with the requirements of Section ILE by the stated
deadlines for submission.

3. A Stipulated Penalty of$1,500 for each day HCHD fails to grant access
to the information or documentation as required in Section ILG of this CCA. (This
Stipulated Penalty shall begin to accrue on the date HCHD fails to grant access.)

4. A Stipulated Penalty of $5,000 for each false certification submitted by


or on behalf of HCHD as part of its Anual Reports or otherwise required by ths CCA.

5. A Stipulated Penalty of $1 ,000 for each day HCHD fails to comply fully
and adequately with any Integrity Requirements of ths CCA. OIG shall provide notice to
HCHD, stating the specific grounds for its determnation that HCHD has failed to comply
fully and adequately with the Integrty Requirement(s) at issue and steps HCHD shall take
to comply with the Integrity Requirements of ths CCA. (This Stipulated Penalty shall
begin to accrue 10 days after HCHD receives notice from OIG of the failure to comply.)
A Stipulated Penalty as described in ths Subsection shall not be demanded for any
violation for which OIG has sought a Stipulated Penalty under Subsections 1-4 of this
Section IILA.

B. Timely Written Requests for Extensions. HCHD may, in advance of the due
date, submit a timely written request for an extension of time to perform any act or fie
any notification or report required by this CCA. Notwithstanding any other provision in
this Section, if OIG grants the timely written request with respect to an act, notification,
or report, Stipulated Penalties for failure to perform the act or fie the notification or
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report shall not begin to accrue until one day after HCHD fails to meet the revised
deadline set by OIG. Notwithstanding any other provision in this Section, ifOIG denies
such a timely written request, Stipulated Penalties for failure to perform the act or file the
notification or report shall not begin to accrue until thee business days after HCHD
receives OIG's written denial of such request or the original due date, whichever is later.
A "timely written request" is defined as a request in writing received by OIG at least five
business days prior to the date by which any act is due to be performed or any notification
or report is due to be fied.

C. Payment of Stipulated Penalties.

1. Demand Letter. Upon a finding that HCHD has failed to comply with
any of the obligations described in Section IILA and after determning that Stipulated
Penalties are appropriate, OIG shall notify to comply; and
HCHD of: (a) HCHD's failure

(b) OIG's exercise of the Stipulated Penalties


its contractual right to demand payment of

(this notification is referred to as the "Demand Letter").

the
2. Response to Demand Letter. Withn 10 days after the receipt of

Demand Letter, HCHD shall either: (a) cure the breach to OIG's satisfaction and pay the
applicable Stipulated Penalties; or (b) request a hearing before an HHS admistrative law
judge (ALJ) to dispute OIG's determnation of noncompliance, pursuant to the agreed
upon provisions set forth below in Section IILE. In the event HCHD elects to request an
ALJ hearing, the Stipulated Penalties shall continue to accrue until HCHD cures, to
OIG's satisfaction, the alleged breach in dispute. Failure to respond to the Demand Letter
in one of these two manners within the allowed time period shall be considered a material
breach of this CCA and shall be grounds for exclusion under Section IILD.

the Stipulated Penalties shall be made by


3. Form of Payment. Payment of

certified or cashier's check, payable to: "Secretary of Health and the Departent of

Human Services," and submitted to OIG at the address set forth in Section ILF.

4. Independence from Material Breach Determination. Except as set forth


in Section IILD .l.c, these provisions for payment of Stipulated Penalties shall not affect
or otherwise set a standard for OIG's decision that HCHD has materially breached this
CCA, which decision shall be made at OIG's discretion and shall be governed by the
provisions in Section IILD, below.

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D. Exclusion for Material Breach of this CCA.

1. Definition of Material Breach. A material breach of ths CCA means:

a. a failure by HCHD to report a Reportable Event, take corrective


action, and make the appropriate refunds, as required in Section ILC;

b. a repeated or flagrant violation of the obligations under ths CCA,


including, but not limited to, the obligations addressed in Section
IILA; or

c. a failure to respond to a Demand Letter concerning the payment


of Stipulated Penalties in accordance with Section III.C.

2. Notice of Material Breach and Intent to Exclude. The parties agree that
a material breach of this CCA by HCHD constitutes an independent basis for HCHD's
exclusion from participation in the Federal health care programs. Upon a determnation
by OIG that HCHD has materially breached this CCA and that exclusion is the
appropriate remedy, OIG shall notify HCHD of: (a) HCHD's material breach; and (b)
OIG's intent to exercise its contractual right to impose exclusion (ths notification is
referred to as the "Notice of Material Breach and Intent to Exclude").

3. Opportunity to Cure. HCHD shall have 30 days from the date of receipt
of the Notice of Material Breach and Intent to Exclude to demonstrate to OIG's
satisfaction that:

a. HCHD is in compliance with the requirements of the CCA cited


by OIG as being the basis for the material breach;

b. the alleged material breach has been cured; or

c. the alleged material breach cannot be cured within the 30-day


period, but that: (i) HCHD has begun to take action to cure the
material breach; (ii) HCHD is pursuing such action with due
diligence; and (iii) HCHD has provided to OIG a reasonable
timetable for curing the material breach.

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the 30-day period, HCHD fails
4. Exclusion Letter. If, at the conclusion of

to satisfy the requirements of Section III.D.3, OIG may exclude HCHD from paricipation
in the Federal health care programs. OIG shall notify HCHD in writing of its
determination to exclude HCHD (this letter shall be referred to as the "Exclusion Letter").
Subject to the Dispute Resolution provisions in Section III£, below, the exclusion shall
go into effect 30 days after the date ofHCHD's receipt of the Exclusion Letter. The
exclusion shall have national effect and shall also apply to all other Federal procurement
and nonprocurement programs. Reinstatement to program participation is not automatic.
After the end of the period of exclusion, HCHD may apply for reinstatement by
submitting a written request for reinstatement in accordance with the provisions at 42
C.F.R. §§ 1001.3001-.3004.

E. Dispute Resolution.

its Demand Letter or


1. Review Rights. Upon OIG's delivery to HCHD of

of its Exclusion Letter, and as an agreed-upon contractual remedy for the resolution of
disputes arising under this CCA, HCHD shall be afforded certin review rights
comparable to the ones that are provided in 42 U.S.C. § 1320a-7(f) and 42 C.F.R. Part
1005 as if they applied to the Stipulated Penalties or exclusion sought pursuant to ths
CCA. Specifically, OIG's determnation to demand payment of Stipulated Penalties or to
seek exclusion shall be subject to review by an HHS ALJ and, in the event of an appeal,
the HHS Departmental Appeals Board (DAB), in a manner consistent with the provisions
in 42 C.F.R. §§ 1005.2-1005.21. Notwithstanding the language in 42 C.F.R. § 1005.2(c),
the request for a hearing involving Stipulated Penaltes shall be made within 10 days after
receipt of the Demand Letter and the request for a hearng involving exclusion shall be
made within 25 days after receipt of the Exclusion Letter.

Title 42
2. Stipulated Penalties Review. Notwithstanding any provision of

of the United States Code or Title 42 of Federal Regulations, the only issues
the Code of

in a proceeding for Stipulated Penalties under ths CCA shall be: (a) whether HCHD was
in full and timely compliance with the requirements of ths CCA for which OIG demands
payment; and (b) the period of noncompliance. HCHD shall have the burden of proving
its full and timely compliance and the steps taken to cure the noncompliance, if any. OIG
shall not have the right to appeal to the DAB an adverse ALJ decision related to
Stipulated Penalties. If the ALJ agrees with OIG with regard to a finding ofa breach of
this CCA and orders HCHD to pay Stipulated Penalties, such Stipulated Penalties shall
become due and payable 20 days after the ALJ issues such a decision uness HCHD
requests review of the ALJ decision is properly
the ALJ decision by the DAB. If

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appealed to the DAB and the DAB upholds the determnation of OIG, the Stipulated
Penalties shall become due and payable 20 days after the DAB issues its decision.

3. Exclusion Review. Notwithstading any provision of the Title 42 of

United States Code or Title 42 of the Code of Federal Regulations, the only issues in a
proceeding for exclusion based on a material breach of this CCA shall be:

a. whether HCHD was in material breach of ths CCA;

b. whether such breach was continuing on the date of the Exclusion


Letter; and

c. whether the alleged material breach could not have been cured
within the 30-day peiiod, but that: (i) HCHD had begun to take
action to cure the material breach withi that period; (ii) HCHD has
pursued and is pursuing such action with due dilgence; and (iii)
HCHD provided to OIG within that period a reasonable timetable for
curng the material breach and HCHD has followed the timetable.

For puroses of the exclusion herein, exclusion shall take effect only after an ALJ
decision favorable to OIG, or, ifthe ALJ rules for HCHD, only after a DAB decision in
favor ofOIG. HCRD's election of its contractual right to appeal to the DAB shall not
abrogate OIG's authority to exclude HCHD upon the issuance of an ALl's decision in
favor ofOIG. If the ALJ sustains the determnation ofOIG and determnes that exclusion
is authorized, such exclusion shall take effect 20 days after the ALJ issues such a
decision, notwithstanding that HCHD may request review of the ALJ decision by the
DAB. If the DAB finds in favor ofOIG after an ALJ decision adverse to OIG, the
exclusion shall take effeCt 20 days after the DAB decision. HCHD shall waive its right to
any notice of such an exclusion if a decision upholding the exclusion is rendered by the
ALJ or DAB. If HCHD, HCHD shall be reinstated effective on
the DAB finds in favor of

the date of the original exclusion.

4. Finality of Decision. The review by an ALJ or DAB provided for above


shall not be considered to be an appeal right arising under any statutes or regulations.
Consequently, the parties to this CCA agree that the DAB's decision (or the ALl's
decision if not appealed) shall be considered final for all purposes under this CCA.

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iv. EFFECTIVE AND BINDING AGREEMENT

HCHD and OIG agree as follows:

A. This CCA shall be binding on the successors, assigns, and transferees of


HCHD;

B. This CCA shall become final and binding on the date the final signatue is
obtained on the CCA;

C. Any modifications to this CCA shall be made with the prior wrtten consent of
the parties to this CCA;

D. OIG may agree to a suspension ofHCHD's obligations under ths CCA in the
event ofHCHD's cessation of paricipation in Federal health care programs. IfHCHD
withdraws from participation in Federal health care programs and is relieved of its CCA
obligations by OIG, HCHD shall notify OIG at least 30 days in advance ofHCHD's
intent to reapply as a paricipating provider or supplier with any Federal health care
program. Upon receipt of such notification, OIG shall evaluate whether the CCA should
be reactivated or modified.

E. The undersigned HCHD signatory represents and warants that it is authorized


to execute ths CCA. The undersigned OIG signatory represents that he is signing ths
CCA in his official capacity and that he is authorized to execute ths CCA.

which constitutes an
F. This CCA may be executed in counterpars, each of

original and all of which constitute one and the same CCA. Facsimiles of signatures shall
constitute acceptable, bindig signatures for purposes of ths CCA.

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ON BEHALF OF THE HARRS COUNTY HOSPITAL DISTRICT

'I /~~f !J7


DA D S. LOPEZ DATE
President and Chief Executi fficer
Harrs County Hospital Distrct

ON BEHALF OF THE OFFICE OF INSPECTOR GENERA


OF THE DEPARTMENT OF HEALTH AND HUMA SERVICES

~
GREGORY E. DEMSKE
Assistat Inspector General for Legal Affairs
YAi7
DATE

Office of Inspector General


United States Department of Health and Human Services

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Appendix A

DECLARTION
The declarants are curently the President and Chief Executive Officer and Vice
President of Corporate Compliance for HCHD and have personal knowledge of the facts
stated herein. The following describes the compliance program and practices (Program)
curently in place at HCHD.

1. The annual budget for the Program is attched hereto as Exhbit 1 and HCHD
shall continue to make available to the Program, at a minimum, the aggregate levels of
funding and resources reflected therein for three years subsequent to the Effective Date.

2. The Program includes a Compliance Officer who is responsible for developing


and implementing policies, procedures, and practices designed to ensure compliance with
Federal health care program requirements. The Compliance Officer also is responsible
for monitoring the day-to-day compliance activities of HCHD. The Compliance Officer
is a member of senior management of HCHD and is not subordinate to the General
Counselor Chief Financial Officer. The Compliance Officer, or other appropriate
compliance personnel, makes periodic (at least quarterly) reports regarding compliance
Managers ofHCHD and is authorized to report on such
matters directly to the Board of

matters to the Board of Managers at any time.

3. The Program includes a Compliance Commttee that is chaired by the


Compliance Officer and that is made up of other members of senior management
necessary to support the Compliance Officer in fulfillng his/her responsibilties under the
Program (~, senior executives of relevant departents, such as biling, clincal, human
resources, audit, and operations).

4. HCHD has in place a Code of Conduct for Federal Health Care Programs that
includes: (a) HCHD's commitment to full compliance with all Federal health care
program requirements, including its commtment to prepare and submit accurate claims
consistent with such requirements; (b) HCHD's requirement that all of its personnel are
expected to comply with all Federal health care program requirements and with the
Policies and Procedures described in Paragraph 5 below; (c) the requirement that all of
HCHD's personnel are expected to report to the Compliance Officer or other appropriate
individual designated by HCHD suspected violations of any Federal health care program
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requirements or ofHCHD's own Policies and Procedures; (d) the possible consequences
to both HCHD and its personnel of failure to comply with Federal health care program
requirements and with HCHD's own Policies and Procedures and the failure to report
such noncompliance; and (e) the right ofHCHD's personnel to use the Disclosure
Program described in Paragraph 8 below and HCHD's commtment to nonretaliation and
to maintain, as appropriate, confidentiality and anonymty with respect to such
disclosures. Each (i) Board of Managers Member, officer, director, and employee; (ii)
contractor, subcontractor, agent, and other person who provides patient care items or
services or who performs billng or coding fuctions on behalf of HCHD; and (iii)
member of the medical staff of HCHD is required to certify in writing that he or she has
received, read, understood, and wil abide by the Code of Conduct for Federal Health
Care Programs. i

the
5. HCHD has in place Policies and Procedures regarding the operation of

Program and HCHD's compliance with Federal health care program requirements and
biling requirements regarding Medicare secondar payer. The Policies and Procedures
are made available to all relevant HCHD personneL. At least annually (and more
frequently, if appropriate), HCHD reviews and updates as necessary such Policies and
Procedures and, if revisions are made, makes available the relevant portions of any
revised Policies and Procedures to all HCHD personnel whose job fuctions relate to the
revised Policies and Procedures.

6. HCHD has in place an anual compliance training program that requires all (i)
Board of Managers Members, officers, directors, and employees to attend at least one
hour of Conduct for Federal
annual compliance training that addres~es HCHD's Code of

Health Care Programs and the operation of the Program2 ; and (ii) contractors,

i The Certification related to the Code of


Conduct for Federal Health Care Programs is
not required for part-time or per diem employees, contractors, subcontractors, agents, and
other persons who are not reasonably expected to work more than 160 hours per year.
Such individuals shall be required to make the appropriate certification at the point when
they work more than 160 hours during the calendar year.
2 The compliance training is not required for part-time or per diem employees,
contractors, subcontractors, agents, and other persons who are not reasonably expected to
work more than 160 hours per year. Such individuals shall be required to receive the
compliance training, however, at the point when they work more than i 60 hours during
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Appendix A
subcontractors, agents, and other persons who provide patient care items or services or
who perform billng or coding fuctions on behalf of HCHD to certify that its persounel
are required to attend at least one hour of annual compliance trainig that addresses
compliance codes of conduct and the operation of a compliance program. In addition,
HCHD wil use its best efforts to encourage its entire medical staff to attend the annual
compliance training described in this Paragraph 6.

HCHD's Program also requires additional hours oftraining for all employees,
contractors, subcontractors, agents, and other persons who provide patient care items or
services or who perform biling, coding, or claims submission functions on behalf of
HCHD. Such additional training addresses: (a) the Federal health care program
requirements regarding the accurate coding and submission of claims; (b) policies,
procedures, and other requirements applicable to the documentation of medical records;
(c) the personal obligation of each individual involved in the claims submission process
to ensure that such claims are accurate; (d) applicable reimbursement statutes, regulations,
and program requirements and diectives; (e) the legal sanctions for violations of Federal
health care program requirements; (f) examples of proper and improper claims
submission practices; and (g) proper procedures for processing Medicare secondary payer
claims. HCHD wil require its contractors and subcontractors who provide patient care
items or services, or who perform biling, coding, or claims submission fuctions on
behalf of HCHD to certify that its personnel receive additional trainng listed in
subsections (a) through (g) above.

HCHD maintains written or electronic records that identify the tye of annual
training provided, the date(s) ofthe training, and the attendees. Persons providing the
trainng are knowledgeable about the subject area. HCHD reviews the training content on
an annual basis and, as appropriate, updates the training to reflect changes in Federal
health care program requirements and/or any issues discovered durng the internal audits
described in Paragraph 7 below.

7. HCHD's Corporate Compliance Departent includes biling and coding


compliance and other personnel who perform periodic reviews to monitor HCHD's
compliance with Federal health care program requirements, including focused reviews
relating to specific risk areas identified by the OIG and HCHD's Compliance Committee
and/or through the Program, including Medicare Secondary Payer and Medicaid Third

the calendar year.


3
The Harrs County Hospital Distrct
Certification of Compliance Agreement
Appendix A
Par Resource claim. HCHD has nine full-time qualified employees whose assignments
include the review of HCHD's compliance with Federal health care program
requirements.

8. HCHD maintains a Disclosure Program that includes a mechansm to enable


individuals to disclose, to the Compliance Officer or some other person who is not in the
disclosing individual's chain of command, any identified issues or questions associated
with HCHD's policies, conduct, practices, or procedures with respect to a Federal health
care program believed by the individual to be a potential violation of crimial, civil, or
admstrative law. HCHD publicizes the existence of the disclosure mechansms to all
personneL.

The Disclosure Program emphasizes a nonretribution, nonretaliation policy and


includes a reporting mechanism for anonymous communcations for which appropriate
confidentiality is maintained. Each disclosure is reviewed by the Compliance Officer, or
appropriate compliance personnel, who either investigates the disclosure or refers the
disclosure to the relevant departent or manager for follow up and any appropriate
corrective action.

The Compliance Officer (or designee) maintains a disclosure log, which includes a
record and summary of each disclosure received (whether anonymous or not), the status
ofHcHD's internal review of the allegations, and any corrective action taken in response
to the internal review.

9. HCHD has in place a policy and procedure for screening all prospective Board
of Managers Members, officers, directors, employees, contractors, subcontractors, agents,
and medical staff members to ensure that they are not Ineligible Persons3 by: (a) requiring
such persons to disclose whether they are an Ineligible Person; and (b) appropriately
queryng the General Services Admnistration's List of Parties Excluded from Federal
Programs (available through the Internet at htt://epls.amet.gov) and the HHS/OIG List

3 An "Ineligible Person" is an individual or entity who: (i) is currently excluded, debarred,


suspended, or otherwise ineligible to participate in the Federal health care programs or in
Federal procurement or nonprocurement programs; or (ii) has been convicted of a
criminal offense that falls within the ambit of 42 U.S.C. § 1320a-7(a), but has not yet
been excluded, debarred, suspended, or otherwise declared ineligible.

4
The Harris County Hospital Distrct
Certification of Compliance Agreement
Appendix A
of Excluded Individuals/Entities (available through the Internet at htt://oig.hhs.gov)
(these lists shall hereinafter be referred to as the "Exclusion Lists"). HCHD also
performs annual screening of its current Board of Managers Members, officers, directors,
employees, contractors, subcontractors, agents, and medical staff members against the
Exclusion Lists and requires all Board of Managers Members, officers, directors,
employees, contractors, subcontractors, agents, and medical staff members to disclose
immediately any debarment, exclusion, suspension, or other event that makes that person
an Ineligible Person.

HCHD also has a policy in place that, ifHCHD has actual notice that an officer,
director, employee, contractor, subcontractor, agent, or medical staff member has become
an Ineligible Person, HCHD wil remove such person from responsibilty for, or
involvement with, HCRD's business operations related to the Federal health care
programs and wil remove such person. from any position for which the person's
compensation or items or services fushed, ordered, or prescribed by the person are paid
in whole or in part, directly or indirectly, by Federal health care programs or otherwise
with Federal funds, at least until such time as the person is reinstated into participation in
the Federal health care programs. (Nothing in this Declaration affects the responsibility
of HcHD to refrain from biling Federal health care programs for items or services
fuished, ordered, or prescribed by excluded individuals or HCHD's liability for
overpayments received by HCHD as a result of billng any Federal h~alth care program
for such items or services.).

If HCHD has actual notice that a Board of Managers Member has become an
Ineligible Person, HCHD wil initiate steps to remove such person from responsibility for,
or involvement with, HCHD's business operations related to the Federal health care
programs and wil initiate steps to remove such person from any position for which the
person's compensation or items or services fuished, ordered, or prescribed by the
person are paid in whole or in part, directly or indirectly, by Federal health care programs
or otherwise with Federal fuds, at least until such time as the person is reinstated into
participation in the Federal health care programs.

5
The Harris County Hospital District
Certification of Compliance Agreement
Appendix A
The undersigned signatory represents and warrants that he/she is authorized to
execute this declaration on behalf ofHCHD.

I declare under penalty ofpeijur that the fore . g is tre and correct.

Executed on this02St'day of

David S. Lopez
President and Chief Executiv Officer
Hars County Hospital Distrct

¿Jc¡ Z. r:~/-h
Walter E. Freitag, Jr.
Vice President of Corporate Compliance
Hars County Hospital Distrct

6
The Haris County Hospital Distrct
Certification of Compliance Agreement
Appendix A
APPENDIX B

OVERPAYMENT REFUND

TO BE COMPLETED BY MEDICARE CONTRACTOR


Date:
Contractor Deposit Control # Date of Deposit:
Contractor Contact Name: Phone #
Contractor Address:
Contractor Fax:

TO BE COMPLETED BY PROVIDER/PHYSICIAN/SUPPLIER
Please complete and orwar to Me icare Contractor. T. is orm, or a simi ar ocument containing the following
information, should accompany every voluntary refund so t at receipt of check is properly recorded and applied.
PROVIDERIHYSICIANISUPPLIERNAME
ADDRESS
PROVIERIHYSICIA/SUPPLIER # CHECK NUBER#
CONTACT PERSON: PHONE # AMOUN OF CHECK
$ CHECK DATE

REFUND INFORMATION

Patient Name HrC #


For each Claim. provide the followIn2::
Medicare Claim Number Claim Amount Refunded $
Reason Code for Claim Adjustment:_ (Select reason code from list below. Use one reason per claim)

(Please list all claim numbers involved. Attach separate sheet, ifnecessary)
Note: If Specifc Patient/HIC/Claim #/Claim Amount data not available for all claims due to Statistical Sampling,
please indicate methodology and formula used to determine amount and reason for
overpayment:
For Institutional Facilties Only:
Cost Report Y ear( s)
(rfmultiple cost report years are involved, provide a breakdown by amount and corresponding cost report year.)
For OIG ReportIn2: ReQuirements:
Do ou have a Co orate Inte .t A eement with oro? Yes No
Reason Codes:
Biling/Clencal Error MSP/Other Paver Involvement Miscellaneous
01 - Corrected Date of Service 08 - MSP Group Health Plan Insurance 13 - Insuffcient Documentation
02 - Duplicate 09 - MSP No Fault Insurance 14 - Patient Enrolled in an HMO
03 - Corrected CPT Code 10 - MSP Liability Insurance 15 - Servces Not Rendered
04 - Not Our Patient(s) II - MSP, Workers Comp.(lncluding l6 - Medical Necessity
05 - Modifier Added/emoved Black Lung 17 - Other (Please Specify)
06 - Biled in Error 12 - Veterans Administration
07 - Corrected CPT Code

The Harris County Hospital District


Certification of Compliance Agreement
Appendix B